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Variable decelerations buy 5 mg propecia overnight delivery, particularly when there is also the presence of normal variability and accelerations cheap propecia generic, are usually not associated with ftal hypoxemia buy propecia in india. Current ftal monitoring equipment also allows fr contraction monitoring along with the ftal heart rate assessment 5mg propecia for sale. It allows fr evaluation of the presence and timing of contractions but does not measure the strength of the contractions. Con tractions that are inadequate in fequency or power may be augmented with an oxytocic agent. Intravenous oxytocin is the drug of choice, as it is efective, inex pensive, and most practitioners are fmiliar with its usage. Oxytocin has a short half-lif, which allows it to be given by continuous infsion and allows fr the rapid cessation of its activity when it is discontinued. Labor augmentation with oxytocin can cause uterine hyperstimulation, defned as the presence of six or more contrac tions in a 10-minute period that causes nonreassuring fetal heart rate abnormali ties (such as late decelerations). This would be managed by reduction in dose or discontinuation of the oxytocin, repositioning of the patient, and providing oxygen via fce mask to the mother. During labor, the fetal head descends through the birth canal and undergoes fur cardinal movements. During initial descent, the head undergoes Hexon, bring ing the ftal chin to the chest. As descent progresses, inteal rotaton occurs, caus ing the ftal occiput to move anteriorly toward the maternal symphysis pubis. Fur ther extension leads to the delivery of the head, which then restitutes via exteral rotaton to fce either to the maternal right or lef side. This corresponds with rota tion of the ftal body, aligning one shoulder anteriorly below the symphysis pubis and the other posterior toward the sacrum. Maternal pushing, along with gentle downward traction on the ftal head, will deliver the anterior shoulder, and upward traction similarly delivers the posterior shoulder. Occasionally, the anterior shoulder will not readily pass below the pubic symphysis. This is called a shoulder dystocia and is an obstetrical emergency, requiring a coordinated efrt by the entire medical team to reduce the dystocia. Maneuvers, including hyperflexion of the hips (McRoberts maneuver), suprapubic pressure, cutting an episiotomy, or rotation of the ftal body in the vaginal canal, are attempted and are usually successfl. Of deliveries in the United States, 20% or more are accomplished via cesarean delivery. The most common indications are a history of prior cesarean delivery, arrest oflabor or descent, ftal distress necessitating immediate delivery, and breech presentation. Operative vaginal delivery can be perfrmed using either frceps or vacuum assistance. These can only be used when the cervix is completely dilated, membranes are ruptured, the presenting part is the vertex of the scalp, and there is no disproportion between the size of the ftal head and maternal pelvis. Ifany of these conditions are not met and delivery must be accomplished urgently, a cesar ean delivery is indicated. Testing is done by swabbing the vagina, perineum, and anus with a sterile culture applicator. Alternatively, ampicillin could also be used, and this is ofen institution depen dent. If there is no true allergy but intolerance to penicillin, cefazolin should be used. For isolates susceptible to the above alternatives, clindamycin is appropriate; in cases of resistance, vancomycin should be used. Variable decelerations are caused by cord compression and late decelerations by uteroplacental insufciency. Rupture of membranes fr less than 18 hours does not preclude her fom receiving prophylaxis as she already has the indication of preterm labor that justifes beginning prophylaxis. The presence of accelerations on a fetal heart tracing is very reassuring and consistent with a fetal pH of greater than 7. Fetal heart rate tracings must be interpreted within the overall clinical sit uation. Reduction in variability shortly afer giving a narcotic pain medi cation may represent fetal sleep cycle; reduction in variability along with repetitive late decelerations may be an ominous sign of fetal distress. She was seen 1 week earlier in the emergency department fr abdominal pain and was diagnosed with nephrolithiasis. Ultimately, she was sent home with pain medications and given instructions to strain her urine fr stones and to fllow up with her primary care physician. She had several routine laboratory tests drawn in the emergency department, copies of which she brings with her. Upon your review of the laboratory values, you note the fllowing (normal values are in parenthesis): sodium 142 mEq/L (135-145); potassium 4. Upon questioning, you learn that she has had multiple episodes of"kidney stones" in the past 2 years. You send the stone to the laboratory fr analysis and order a repeat serum calcium level. The results show that the stone is made of calcium oxalate; the serum calcium is still elevated at 11. She had an ini tial serum calcium level that was elevated, as was the repeat serum calcium 1 week later. She takes no medications, and has a fmily history only signifcant fr hypertension. Many times, patients with hypercalcemia are asymptomatic and an elevated calcium level is fund unexpectedly on routine laboratory studies. The diagnostic workup is designed to distinguish parathyroid dys fnction fom other etiologies so that optimal treatment and management can be pursued. This may occur as a response to low dietary calcium intake or a defciency of vitamin D. Because the serum calcium is partially bound to albumin, abnormally low serum albumin levels will afect the measure ment of calcium, thus causing a misinterpretation of an abnormal calcium level. With patients fund to have a concomitant hypoalbuminemia, the ionized calcium can be measured directly. A "corrected" serum calcium is provided by the frmula: "Corrected" serum calcium= [0. Causes ofhypercal cemia include a increase in calcum resorpton fom bone, decreased renal excreton of calcium, ora increase in calcium absorpton fom the gastrointestnal tract. When calcium levels increase, calcitonin, produced by the thyroid parafllicular cells, attempts to lower calcium levels through renal excretion of calcium and by oppos ing osteoclast activation. This promotes osteoclast activation, which mobilizes calcium fom bone and efects calcium resorption at the kidneys, thereby retaining circulat ing calcium. If this occurs beyond the normal bounds of maintaining calcium homeostasis, hypercal cemia will occur. The most common cause ofhypercalcemia in the ambulatory patent is hyperarathyroidism. It is usefl to cat egorize the etiologies of hypercalcemia into fve main areas: parathyroid hormone related, malignancy, renal failure, high bone turnover, and those related to vitamin D (Table 17-1). Clinical Manifestations of Hypercalcemia Normal values of serum calcium range fom 8 to 10 mg/dL. The classic mnemonic "stones, bones, psychic groans, and abdominal moans" is usefl to categorize the constellation of physical symptoms associated with hypercalcemia (Table 17-2). Diagnostic Approach The frst step in the evaluation is a carefl history to try to establish a cause and to assess fr manifestations. The history should include fmily history of calcium disorders, such as renal stones or malignancy. A carefl review of medications should also take place, to include not only prescription medications but also over-the-counter supplements. Furthermore, his tory of immobilization secondary to hospital stay or recent injury should be looked into as prolonged immobilization can cause massive bone demineralization and hypercalcemia. At this point, if the hypercalcemia is mild and the patient is asymp tomatic, it is acceptable to stop any suspect medication(s) and repeat the serum calcium level.
This suggests that although inspiratory effort is reduced buy propecia 5mg low price, the mechanical breath delivered by the ventilator exceeds what is required by the patient purchase propecia 1 mg overnight delivery. Setting the expiratory trigger at a higher than usual percentage of peak inspiratory ﬂow attenuates the adverse effects of delayed cycling 5 mg propecia visa, improves patient–ventilator synchrony purchase generic propecia line, and reduces inspiratory muscle effort. Interfaces are therefore interchangeable in clinical practice, although adjustment of the ventilator settings may be required. Ventilator tubing Excessive dead space in the tubing between the ‘Y’ piece and the patient should be avoided. Condensate in dependent parts of the ventilator tubing can lead to auto-triggering. Modes of ventilation have attempted to match the patient’s inspiration and expiration to the ventilator inspiration and expiration, and to ensure that the patient receives more assistance when demand is high and less assistance when demand is low. Clinical importance of ventilator asynchrony The most important example of asynchrony is the mismatch between the patient’s (neural) inspiration and the ventilator’s inspiratory time. If severe, this can lead to: • Fighting against the ventilator • Increased use of sedatives • Prolonged duration of mechanical ventilation and increased frequency of tracheotomy. These muscles already have to cope with increased elastic, resistive, and threshold workload. This increased load can be overcome with ease in patients with well-preserved muscular force, but in difﬁcult-to-wean patients this force–load imbalance can signiﬁ- cantly hamper the process of weaning from mechanical ventilation. Poor patient– ventilator interaction during sleep can lead to sleep fragmentation, frequent arousals, and inadequate correction of nocturnal hypoventilation. It does not mean that asynchrony does not present a problem in patients with other diseases. Problem solving The ventilatory mode In approximately 70% of patients the most common assisted modes of ventilation do not cause major asynchronies. Pressure support may be primarily time cycled or time cycling may be set as a backup if ﬂow cycling fails. The characteristics of the ventilator Most available ventilators synchronize satisfactorily in most cases. There are several studies comparing the in vitro characteristics of the various ventilators, and the knowledge of these results may eventually drive the decision of the clinician to use a speciﬁc ventilator. Ventilator settings Alteration of the ventilator settings is the best available method to improve patient–ventilator interaction. Ventilator inspiration continues into patient (neural) expiration when the inspiratory muscles have stopped contraction. This leaves inadequate time for expiration and leads to ‘breath stacking’ and dynamic hyperinﬂation. The following inspiration starts at a high lung volume, when the pressure at the airway opening is still signiﬁcantly positive. Therefore, the inspiratory effort does not create a pressure gradient capable of being sensed by the ventilator. In the presence of severe expiratory ﬂow limitation, a more sensitive trigger (expiration staring at a higher percentage of peak ﬂow) may reduce the number of ineffective efforts. If using a helmet, increasing the ‘usual’ baseline inspiratory and expiratory pressures by 50%, and increasing the pressurization rate, reduces the number of asynchronies. However, pharmacological sedation should be used cautiously, since confusion and agitation may also be caused by hypoxia and hypercapnia. Opioids such as morphine and fentanyl are powerful analgesics, but even at therapeutic doses will cause respiratory depression. Other adverse effects include hypotension, bradycardia, ileus, delirium, and agitation. It is reasonable to administer small doses of opioids (fentanyl, morphine) where blunting of respiratory drive is desirable. It is indicated for younger patients, for chronic benzodiazepine users, and for patients with preserved lean mass and muscular force, where a mild muscle relaxant effect elicited by benzodiazepines can be desirable. Particularly in patients with airﬂow limitation it may cause increased dura- tion of mechanical ventilation and increased frequency of tracheostomy. The clinician should consider how best to correct this harmful interaction between the ‘two brains’ (i. Acute respiratory failure and forced ventilatory efforts can profoundly alter cardiovascular function, just as heart failure can alter ven- tilation and gas exchange. Many of these effects are predictable and can also be used to diagnose cardiovascular status. Heart–lung interactions involve four basic concepts: • Inspiration increases lung volume. Haemodynamic effects of changes in lung volume Lung inﬂation: • Alters the ﬂow characteristics of venous return • Affects pulmonary vascular resistance • Compresses the heart in the cardiac fossa—at high lung volumes this can limit cardiac volumes in a similar fashion to cardiac tamponade • Alters autonomic tone. Each of these processes may predominate in determining the ﬁnal cardio- vascular state. Venous return The major determinants of the hemodynamic response to increases in lung volume are mechanical in nature. Inspiration alters right atrial pressure and induces diaphragmatic descent, both of which alter venous return. Venous return is a function of: • The ratio of the pressure difference between the right atrium and the systemic venous reservoirs • The resistance to venous return. Increased intra-abdominal pressure (diaphragmatic descent) increases abdominal venous pressure and augments venous blood ﬂow. This increases hepatic outﬂow resistance, decreasing splanchnic venous reservoir ﬂow. Thus, increasing lung volume may increase, decrease, or not alter venous return depending on which of these factors are predominant. Usually: • Spontaneous inspiration increases venous return • Positive pressure inspiration decreases venous return in normo- and hypovolemic states and in patients with hepatic cirrhosis • Positive pressure inspiration increases venous return only in volume overloaded states. Hyperinﬂation therefore increases pulmonary vascular resistance and pulmonary artery pressure. Autonomic tone Small tidal volumes (<10mL/kg) increase heart rate by vagal withdrawal (respiratory sinus arrhythmia). Larger tidal volumes (>15mL/kg) decrease heart rate, arterial tone, and cardiac contractility by increased vagal tone and sympathetic withdrawal. These effects are probably only relevant in the diagnosis of dysautonomia and in the care of neonatal subjects where autonomic tone is high. Haemodynamic effects of changes in intrathoracic pressure The heart within the thorax is a pressure chamber within a pressure chamber. Venous return Variations in right atrial pressure represent the major factor determining the ﬂuctuation in pressure gradient for systemic venous return during ventilation. Ventilation as exercise Spontaneous ventilatory efforts are exercise and represent a metabolic load on the cardiovascular system. Cardiovascular insufﬁciency and failure to clear airway secretions are the two most common causes of failure to wean from mechanical ventilation. Volume responsiveness: • Ventricular volumes vary with positive pressure ventilation. Numerous studies have documented that quantifying this stroke volume or pulse pressure variation allows one to identify those subjects who are volume responsive. Thus, the clinical utility of stroke volume or pulse pressure variation to identify subjects who are volume responsive is only applicable during positive pressure breathing. Being volume responsive does not equate to the need for ﬂuid resuscitation, which is a clinical determination. Dealing effectively with this common problem requires the clinician to understand the potential interactions between the treatment instituted and the underlying pathophysiological process. It should be read in conjunction with b Respiratory physiology and pathophysiology, p. Increase FiO2 • Increasing FiO2 quickly corrects hypoxaemia due to hypoventilation. As shunt fraction increases above 20%, increases in FiO2 have less effect on PaO2.
However purchase 5 mg propecia free shipping, owing to limited efficacy and flu-like reactions order cheap propecia online, oprelvekin is not often used buy propecia master card. Caution should be exercised when performing procedures that might promote bleeding discount 5 mg propecia amex. Blood pressure cuffs should be applied cautiously because overinflation may cause bruising or bleeding. Anemia Anemia is defined as a reduction in the number of circulating erythrocytes (red blood cells). Although anticancer drugs can suppress erythrocyte production, anemia is much less common than neutropenia or thrombocytopenia. Because circulating erythrocytes have a long life span (120 days), which usually allows erythrocyte production to recover before levels of existing erythrocytes fall too low. If anemia does develop, it can be treated with a transfusion or with erythropoietin (epoetin alfa or darbepoetin alfa), a hormone that stimulates production of red blood cells. Because transfusions require hospitalization, whereas epoetin can be administered at home, epoetin therapy can spare the patient inconvenience. First, it cannot be used in patients with leukemias and other myeloid malignancies (because it can stimulate proliferation of these cancers). Second, it shortens survival in all cancer patients and hence is indicated only when the treatment goal is palliation. Clearly, erythropoietin should not be used when the goal is cure or prolongation of life. Stomatitis Stomatitis (inflammation of the oral mucosa) often develops a few days after the onset of chemotherapy and may persist for 2 or more weeks after treatment has ceased. Inflammation can progress to denudation and ulceration and is often complicated by infection. Topical antifungal drugs may be needed to control infection with Candida albicans. For patients with mild stomatitis, pain can be managed with a mouthwash containing a topical anesthetic (e. For patients being treated for hematologic malignancies, palifermin [Kepivance], a chemoprotective agent and keratinocyte growth factor, can decrease the severity of stomatitis. Diarrhea By injuring the epithelial lining of the intestine, anticancer drugs can impair absorption of fluids and other nutrients, thereby causing diarrhea. Diarrhea can be reduced with oral loperamide, a nonabsorbable opioid that slows gut motility by activating local opioid receptors. Nausea and Vomiting Nausea and vomiting are common sequelae of cancer chemotherapy. These responses, which result in part from direct stimulation of the chemoreceptor trigger zone, can be both immediate and dramatic and may persist for hours or even days. You should appreciate that nausea and vomiting associated with chemotherapy are much more severe than with other medications. Whereas these reactions are generally unremarkable with most drugs, they must be considered major and characteristic toxicities of cytotoxic drugs. These drugs offer three benefits: (1) reduction of anticipatory nausea and vomiting, (2) prevention of dehydration and malnutrition secondary to frequent nausea and vomiting, and (3) promotion of compliance with chemotherapy by reducing discomfort. The regimen of choice for patients taking highly emetogenic drugs consists of aprepitant [Emend], dexamethasone, and a serotonin antagonist, such as ondansetron [Zofran]. The use of antiemetics for chemotherapy-induced nausea and vomiting is discussed in Chapter 64. Other Important Toxicities Alopecia Reversible alopecia (hair loss) results from injury to hair follicles. Hair loss begins 7 to 10 days after the onset of treatment and reaches maximal loss in 1 to 2 months. In fact, for many cancer patients, alopecia is second only to vomiting as their greatest treatment-related fear. For patients who choose to wear a hairpiece or wig, one should be selected before hair loss occurs. Hairpieces are tax deductible as medical expenses and are covered by some insurance plans. To some degree, hair loss can be prevented by cooling the scalp while chemotherapy is being administered. Cooling causes vasoconstriction and thereby reduces drug delivery to hair follicles. Unfortunately, scalp cooling is uncomfortable, causes headache, and creates a small risk for cancer recurrence in the scalp (because drug delivery is reduced). Reproductive Toxicity The developing fetus and the germinal epithelium of the testes have high growth fractions. As a result, both are highly susceptible to injury by cytotoxic drugs, especially the alkylating agents. Risk is highest during the first trimester, and hence chemotherapy should generally be avoided during this time. However, after 18 weeks of gestation, risk appears to be very low: according to a 2012 report in Lancet, exposure during this time does not cause neurologic, cardiac, or any other fetal abnormalities. Drug effects on the ovaries may result in amenorrhea, menopausal symptoms, and atrophy of the vaginal epithelium. Hyperuricemia Hyperuricemia is defined as an excessive level of uric acid in the blood. Hyperuricemia is especially common after treatment for leukemias and lymphomas (because therapy results in massive cell kill). The major concern with hyperuricemia is injury to the kidneys secondary to deposition of uric acid crystals in renal tubules. In patients with leukemias and lymphomas, in whom hyperuricemia is likely, prophylaxis with allopurinol is the standard of care. Local Injury From Extravasation of Vesicants Certain anticancer drugs, known as vesicants, are highly chemically reactive. These drugs can cause severe local injury if they make direct contact with tissues. Vesicants are administered intravenously, usually into a central line (because rapid dilution in venous blood minimizes the risk for injury). Extreme care must be exercised to prevent extravasation because leakage can produce high local concentrations, resulting in prolonged pain, infection, and loss of mobility. Severe injury can lead to necrosis and sloughing, requiring surgical débridement and skin grafting. Because of the potential for severe tissue damage, vesicants should be administered only by clinicians specially trained to handle them safely. Unique Toxicities In addition to the toxicities discussed previously, which generally apply to the cytotoxic drugs as a group, some agents produce unique toxicities. For example, a number of drugs can cause peripheral sensory neuropathy, manifesting as numbness or tingling in the fingers and toes and around the mouth and throat. Neuropathy may impede activities of daily living, such as buttoning clothing, writing, or just holding things. Anthracyclines such as daunorubicin and doxorubicin can cause serious injury to the heart. Carcinogenesis Along with their other adverse actions, anticancer drugs have one final and ironic toxicity: these drugs, which are used to treat cancer, have caused cancer in some patients. Cancers caused by anticancer drugs may take many years to appear and are hard to treat. Making the Decision to Treat From the preceding discussion of toxicities, it is clear that cytotoxic anticancer drugs can cause great harm. Given the known dangers of these drugs, we must ask why such toxic substances are given to sick people at all. The answer lies with the primary rule of therapeutics, which states that the benefits of treatment must outweigh the risks. That is, although the toxicities of the anticancer drugs can be significant, the potential benefits (cure, prolonged life, palliation) justify the risks. There are patients whose chances of being helped by chemotherapy are remote, whereas the risk for serious toxicity is high. Because the potential benefits for some patients are small and the risks are large, the decision to institute chemotherapy must be made with care. Before a decision to treat can be made, the patient must be given some idea of the benefits the proposed therapy might offer. For treatment to be justified, there should be reason to believe that at least one of these benefits will be forthcoming.
T here continues to be correlation between maternal dis- ease st age at t he t ime of diagnosis wit h t he viral load and t ransmission rat es purchase propecia online now. W h en loads are reduced to undetectable levels order 1 mg propecia otc, transmission to the fetus becomes uncom- mon purchase propecia with american express. In pregnancy purchase propecia 1 mg with mastercard, the viral load should be evaluated monthly until it is no longer detect- able. Combination retroviral therapy decreases the risk of perinatal transmission to < 2%, and the best route of delivery is not clear. There is some evidence that cesar ean d eliver y can fu r t h er d ecr ease ver t ical t r an sm ission, but cesar ean d eliver y increases mat ernal risks of infect ion and h emorrhage. Patients should have regular monit oring of liver funct ion t est s and blood count s t o det ect toxicit y. He p a t it is The s t in g HepatitisBsurfaceantigen testingisrecommended for allpregnant patients. Those wit h co-infect ion should be t reated with ant iviral agent such as tenofovir and lami- vu d in e. I n fan t s sh o u ld r eceive h ep at it is B im m u n o glob u lin ( Ig) at b ir t h an d st ar the vaccination within 12 hours of birth. Deciding whether to treat hepatitis C with interferon and/ or ribavirin in pregnancy is complicated; ribavirin is associat ed wit h fet al anomalies when given around the time of conception of both men and women (category X). It h as a p r o p en sit y fo r t r an sit io n al an d co lu m n ar ep it h elia. Erythromycin eyedrops are an effective means of preventing chlamydial conju n ct ivit is. W hich of the following is the most likely met h od that the pat ient became in fect ed? Chlamydia is not typically seen on Gram stain because it is an intracel- lular organism. It does h ave a propensit y for columnar and t ransit ional epi- thelia, and it is a leading cause of preventable blindness worldwide. H owever, the pr esent at ion of t he pneumonia is not t ypically associat ed wit h high fever or sepsis. Chlamydia is an obligate intracellular organism associated with late postpartum endometritis and has a long replication cycle. Erythromycin eyedrops are an effect ive means of prevent ing gonococcal eye infect ion but chlamydial infection must be treated systemically with erythromycin. Gonococcal cervicitis is more likely to disseminate during pregnancy, and a pat ient may present wit h sept ic art hrit is, art hralgias, and pustular skin lesions. O ral amoxicillin is well t oler at ed an d effect ive t reat ment of ch lamydial cer- vicitis in pregnancy. Erythromycin estolate can lead to liver dysfunction in pregnancy; thus, the estolate salt is contraindicated in pregnant women. D oxycyclin e, or t et r acyclin e, is cont r ain d icat ed in pr eg- nancy because of the possibility of staining neonatal teeth. Ciprofloxacin is also contraindicated in pregnancy because it may lead to neonatal musculoskeletal problems. Because labor has already begun, elective cesarean delivery will not affect vertical transmission. In other words, the cesarean would need to be performed prior to rupture of membranes or labor to effectively decrease vertical transmis- sion. Intravenous Z D V and minimizing trauma to the baby, such as avoiding fet al scalp elect rode, int raut erin e pressure cat h et ers, forceps, an d vacuum deliver y, is advisable. W h en a pat ient h as a posit ive h epat it is B su r face ant igen result, it mean s the individual has replicating virus; the next step is to determine the stage: acute, chronic, or chronic carrier. Liver function tests and IgM hepatitis B core Ab, and hepatitis B e antigen and antibody can help to make this determination. Ver t ical t r an smission in cr eases wit h h igh vir al load, pr olon ged r upt ur e of mem - branes, and invasive procedures. Breast feeding does not seem to increase the risk of transmission unless there is cracked or bleeding nipples. Antiviral therapy is usually not used in pregnancy due to the side effects; ribavirin in particular is category X and usually avoided in pregnancy. She states that over the last day, she has been feeling as though her “heart is pounding. The fetal heart rate tracing shows a baseline in the 160 bpm range without decelerations. Best management for this condition: A β-blocker (such as propranolol), cortico- st eroids, and propylt h iouracil (P T U ) or met himazole. Know that the most common cause of hyperthyroidism in the United States is Graves disease. Co n s i d e r a t i o n s This 18-year-old woman at 35 weeks’gestation has a history of hyperthyroidism due to Graves disease. In the United States, the majority of hyperthyroidism is due to Graves disease; the clinical presentation is typically that of a painless, uniformly enlarged t hyroid gland wit h occasional propt osis. For wh at ever reason, wh ich is n ot st at ed, the pat ient h as sympt oms of in creased thyrotoxicosis of 1-day duration. Some possible reasons include noncompliance wit h t he medicat ion, or a st ressor, such as surgery or an illness. T his woman not only has the nervousness and palpitations of hyperthyroidism, but also auto- nomic instability, which is the hallmark of thyroid storm. T hyroid st orm must be recognized because it carries a significant risk of mortality. The therapy consists of a β-blocking agent, such as propranolol, cor t icost er oid s, an d ant i-t h yr oid m edicat ion s. T h e pr efer r ed agent in this set t in g is P T U because of it s fast er onset of act ion and abilit y t o inh ibit peripheral con- ver sio n o f T 4 t o T 3. I n a n o n p r egn a n t patient o r a p r egn a n t patient wh o is su f- ficien t ly ill, a sat u r at ed solu t ion of p ot assiu m iod id e or al d r op s may also be u sed ; however, this agent may affect the fetal thyroid gland. Met himazole has been rarely linked wit h possible fet al scalp defect s an d aplasia, so it is n ot u sed in the first t rimest er. It is t he most common cause of t hyrotoxicosis in t he Unit ed St at es, associat ed wit h a diffusely enlarged goit er. Symptoms of thyrotoxicosis include tachycardia, heat intolerance, nausea, weight loss or failure t o gain weight despit e adequat e food int ake, t hyromegaly, t hyroid bruit, tremor, exophthalmos, and systolic hypertension. These antibodies stimulate the thyroid gland to produce more thyroid hormone, leading to the symptoms responsible for thyrotoxicosis. Treatment during pregnancy may be medical or surgical; however, generally, hyperthyroidism in pregnancy is managed medi- cally. P r opylt h iou r acil is gen er ally accept ed as the dr u g of ch oice in pr egn an cy. P T U inhibit s t he peripheral conversion of T t o T b u t m ay cr o ss the p lacen t a som ewh at. T hyroidect omy is reserved for t hose pat ient s who are noncompliant wit h or cannot tolerate medical t herapy. Symptoms suggestive of storm include altered mental status, hyperthermia, cardiac arrhythmia, hypertension, vomiting, and diarrhea. In fect ion, sur ger y, labor or deliv- ery, or ot h er st ressors may t rigger t hyroid st orm in pat ient s wit h hypert hyroidism. Congestive heart failure can result from the effects of thyroxine on the myocar- dium. Because the mortality rate associated with thyroid storm is high, accurate early ident ificat ion is crucial. W hen ident ified antenat ally, t he fetus should be t reat ed eit her wit h mat ernal administ rat ion of P T U or inject ion of int ra-amniot ic t hyroxine (fet al hypot hyroid- ism). Failure to identify fet al thyrotoxicosis can result in nonimmune hydrops and fet al demise. Po st p a r t u m Th yro id it is About 5% of post par t um women will h ave post par t um t h yroidit is wit h the peak onset at 6 months post delivery. T here are three phases: h yp er t h yr o id, h yp o t h yr o id, and eut hyroid (although some will remain hypot hyroid). The pathophysiology is similar t o H ashimot o’s t hyroidit is (lymphocyt ic infilt rat ion) and is associated wit h antimicrosomal antibodies and antiperoxidase antibodies.